Consumer Directed Care

Consumer Directed Care

Employer Service Agreement

Care Manager Name: ______Date: ______

Consumer Name: ______Date of Birth: ______

Address: ______City: Zip: ______

Phone Number: ______Fiscal Intermediary: ______

Service Agreement Sections

Section A. Consumer Assessment to Manage CDC Services ...... Page 2 & 3

Section B. Consumer/Surrogate Responsibilities ...... Page 4

Section C. Worker Roles and Responsibilities ...... Page 5

Section D. Worker Backup Plan/List ...... Page 5

Section E. Agency - ASAP Responsibilities ...... Page 6

Section F. Fiscal Intermediary (FI) Responsibilities ...... Page 6

Section G. Signatures ...... Page 7

Glossary of Terms

ASAP – Aging Services Access PointFI – Fiscal Intermediary

CDC – Consumer Directed Care

ADLs - Activities of Daily LivingIADLs - Instrumental Activities of Daily Living

Introduction

The Service Agreement is an important part of the consumer’s plan of care while participating in Consumer Directed Care and will be developed based on the consumer’s individual needs. The Service Agreement assesses the consumer’s ability to manage CDC and describes the roles and responsibilities of the consumer, the surrogate, if any, the worker, the ASAP, and the FI.

This agreement will be reviewed and modified as appropriate:

• At the time of the consumer’s redetermination for services;
• When the consumer is not managing CDC effectively as evidenced bythe consumer exhibiting a pattern of overutilization, or inappropriate use of CDC services, and not responding to intervention from a Care Manager; or is not managing CDC services effectively;
• When the consumer, or the Fiscal Intermediary requests a review;
• When there is a significant change in the consumer’s medical, cognitive, or emotional condition that affects the consumer’s ability to manage CDC services independently.

Section A. Consumer Assessment to Manage CDC Services

The result of the Consumer Assessment to Manage CDC Services is a decision that either:

• The consumer can manage CDC services independently; or

• The consumer requires or prefers the assistance of a surrogate to manage some or all aspects of the CDC service.

Reason for Assessment:

□Initial assessment

□Change in condition - if checked, describe: ______

□Difficulty managing CDC services

□Requested by the FI

Preference

Does the consumer preferto have the assistance of a surrogate to manage all aspects of the CDC service?

□yes □no

If “no”, the consumer prefers to manage some or all aspects of the CDC service, proceed to Guardianship Status.

If “yes”, the consumer prefers to have the assistance of a surrogate to manage all aspects of the CDC service. No further assessment is necessary. Proceed to Part III.

Guardianship Status

Does the consumer have a court-appointed legal guardian? □yes □no

If no, proceed to Part I, Section 1, Communication and Decision Making.

If yes, no further assessment is necessary: a surrogate is required. Complete (c) and (d) and proceed to Part III.

c. Name of the legal guardian: ______

d. Describe the evidence of guardianship: ______

I. Assessment

1. Communication and Decision Making

A “yes” response to question (a) or a “no” response to question (b), (c), or (d) indicates that the consumer requires the assistance of a surrogate with communication and decision making.

a. Does the consumer demonstrate cognitive/behavioral disabilities that would impair the consumer’s ability to self-direct his or her care? □ yes □no

If “yes,” list the cognitive/behavioral disability: ______

If “yes,” describe how the consumer’s ability to self-direct would be impaired: ______

b. Does the consumer remember important information? □yes □no

c. Can the consumer communicate his or her needs effectively? □ yes □no

d. Does the consumer manage his or her own finances? □ yes □no

Result:

□The consumer does not require the assistance of a surrogate with communication and decision making.

□The consumer requires the assistance of a surrogate with communication and decision making.

2. Knowledge of Disability and Related Conditions

A “no” response to any question indicates that the consumer requires the assistance of a surrogate with knowledge of disability and related conditions.

a. Is the consumer able to describe his or her disability and related conditions? □yes □no

b. Is the consumer able to describe a plan to manage medications (schedules and dosages)? □yes □no

c. Is the consumer able to describe the use of any assistive devices or adaptive equipment? □yes □ no

Result:

□The consumer does not require the assistance of a surrogate to understand his or her disability and related conditions.

□The consumer requires the assistance of a surrogate to understand his or her conditions.

3. Knowledge of Personal Assistance Needs

A “no” response to question (a), (b), (c), or (d) indicates that the consumer requires the assistance of a surrogate to understand personal assistance needs and routines.

a. Is the consumer able to describe a routine day and give examples of assistance needed, such as bathing, toileting, and other personal care? □ yes □no

b. Can the consumer describe the preferred transfer method? □yes □no

c. Can the consumer describe meal preparation and dietary needs? □yes □no

d. Can the consumer describe housekeeping needs? □yes □no

Result:

□The consumer does not require the assistance of a surrogate with knowledge of personal assistance needs.

□The consumer requires the assistance of a surrogate with knowledge of personal assistance needs.

4. Ability to Employ Workers

A “no” response to any question indicates that the consumer requires the assistance of a surrogate to employ workers.

a. Can the consumer describe how to recruit, hire, and schedule a worker? □ yes □no

b. Is the consumer able to describe how to train and supervise a worker? □yes □no

c. Can the consumer describe the backup plan he or she will use if a worker is sick or absent? □yes □no

d. Can the consumer complete activity forms correctly? □yes □no

Result:

□The consumer does not require the assistance of a surrogate to employ workers.

□The consumer requires the assistance of a surrogate to employ workers.

II. Assessment Summary

 The consumer needs the assistance of a surrogate in the following areas (check all that apply.)

□Communication and decision making

□Understanding of his or her disability and related condition

□Understanding his or her personal assistance needs and routines

□Employing workers

III. Decision - Check one:

□The consumer is able to independently perform all tasks required to manage the CDC program and does not require the assistance of a surrogate.

□The consumer requires the assistance of a surrogate to perform some or all of the CDC management tasks that the consumer is unable to perform.

If the consumer is assessed to require a surrogate, one must be identified for CDC services to commence or continue.

If the consumer receives skills training that enable the consumer to independently manage the CDC program, revise this form to reflect any changes.

Section B. Consumer/Surrogate Responsibilities

Consumer and/or surrogate to initial who will be responsible for each area below:

Assessments and Evaluations: / Consumer / Surrogate
Cooperating with the ASAP during assessments, evaluations, and reevaluations
CDC Management Tasks:
Ensuring consumer does not bill for services during a hospital or nursing facility stay
Employing workers for no more than the number of hours authorized
Ensuring that workers perform the tasks described in this Agreement
Notifying the FI of the date of hire and termination and a worker’s change of address
Working with the ASAP to develop a backup list when a regular worker cannot work
Working with the FI and the ASAP to resolve any disagreements or complaints
Consumer Responsibilities as an Employer:
Complying with applicable state and federal labor laws, including child labor laws.
Hiring, scheduling, training, and terminating workers
Completing and signing all employment forms as required by the FI
Submitting activity forms (timesheets) in the time frame required by the FI
Ensuring that the consumer’s activity forms (timesheets) correctly identify the hours that the worker worked for each pay period, and that the name of the worker is correct
Functional Skills Training: The ASAP can provide Skills Training in any of the following. Check any areas of need and indicate who will be trained: / Consumer / Surrogate
Program Rules and Requirements
□Rights and responsibilities as a consumer or surrogate
□Program rules and regulations
□Roles and responsibilities of other program participants (ASAP, FI)
Worker Training
□Functions of Workers
□Assisting with ADLs and IADLs
□Scheduling of workers so hours are used correctly
CDC Management
□Hiring, recruiting, training, terminating, and supervising workers
□Evaluating the worker’s performance
□Developing/maintaining a list of people to call if a worker is unable to work
□Using the appropriate number of hours per week
□Identifying tasks to be covered by the CDC program
Personal Health Care Maintenance
□Understanding and describing the consumer’s medical conditions, routines and treatments, including medication schedules and dosages, nutritional planning, bowel and bladder routine, and range-of-motion routine
Emergency Management
□Describing how and when to use a physician /local hospital emergency room
□Understanding appropriate treatment/equipment for dealing with an emergency
□Maintaining a list of emergency phone numbers and procedures
Fiscal Intermediary
□Completing and submitting accurate Activity Forms in the time frame specified
□Completing paperwork required by the FI
Other Areas (Describe):

Section C. Worker Roles and Responsibilities

1. What to Look for When Hiring a worker:

• meets all legal requirements to work in the United States (the FI can tell the consumer what these are)

• is able to understand and carry out instructions given by the consumer and/or the consumer’s surrogate

• is willing and able to receive training and supervision in all services from the consumer and the surrogate

•provides the consumer with care that is free from abuse and neglect.

Section D. CDC Backup Plan/List

It is very important that the consumer have a plan in place in the event a worker is unable to work.

Describe what will be done and who will be contacted to work if the regularly scheduled worker is unexpectedly not available. ______

______

______

List all people who are available to work if a worker is unavailable to work his or her regularly scheduled hours. This list should be kept current. The consumer will need to contact the FI if the person on the backup list wants to be paid.

Worker Name / Phone # / Address / Completed FI
Paperwork (Y/N)

Section E. Agency – ASAP Responsibilities

The ASAP is responsible for all of the following:

1. Employer Tasks Agreement

• Developing and reviewing this Agreement with the consumer and the consumer’s surrogate, if any;

• Providing the consumer and the consumer’s surrogate, if any, with a copy of this Service Agreement giving the consumer an opportunity to disagree with the Employer Service Agreement; and providing a way to resolve any disagreements as soon as possible; and

• Monitoring the Agreement to ensure that the consumer, or the consumer’s surrogate, if any, is managing the CDC program successfully.

2. Customer Service:

• Seeking and including the consumer’s input into the services provided by the ASAP;

• Providing the consumer with a copy of the ASAP’s complaint and grievance process and working with the consumer to resolve any complaints about services in a timely fashion;

• Having a telephone system that the consumer can call and leave a message with after business hours;

• Responding to consumer inquiries and voicemails within two business days;

• Providing written information to consumers in an understandable language and format; and

• Providing services that are culturally sensitive.

3. Intake and Orientation and Functional Skills Training:

• If the consumer is new to the CDC program, providing intake and orientation services to the consumer to begin the eligibility determination process for CDC services;

• Providing skills training to instruct the consumer and the surrogate, if any, about how to manage the program;

• Teaching the consumer ways to recruit, hire, train, schedule, evaluate, and terminate workers;

• Working with the consumer to establish a list of persons whom the consumer can call to work if the regularly scheduled worker is unable to work;

• Informing consumer about the FI and helping the consumer complete paperwork required before hiring a worker;

• Informing the consumer and surrogate, if any, about ways to have services that are safe, such as the availability of Criminal Offender Record Information (CORI), Disabled Persons Protection Commission (DPPC), the Sex Offender Registry, and the Elder Services hotline; and

• Providing skills training to the consumer as described in this Service Agreement, and at the request of the consumer or FI.

Section F. Fiscal Intermediary (FI) Responsibilities

The FI is responsible for all of the following:

1. Employer-Required Tasks

• Performing the employer-required tasks that are described in the ASAP-Consumer Agreement;

• Issuing checks for workers; and

• Ensuring the consumer has an active authorization from the ASAP for services before paying workers.

2. Customer Service

• Answering consumer telephone calls about activity forms (timesheets), tax forms, and the functions of the FI (When consumer concerns cannot be addressed by telephone, consumers may be referred to the ASAP.)

• Operating a toll-free telephone service during business hours from 9:00 A.M. to 5:00 P.M., Monday through Friday, excluding holidays;

• Operating a toll-free answering or voice messaging service during non-business hours;

• Providing the consumer with a copy of the FI’s complaint and grievance process and working with the consumer to resolve any complaints about the FI’s services in a timely fashion;

• Notifying the consumer’s ASAPand the consumer if the consumer is sending in Activity Forms (timesheets) for more than the hours per month authorized;

• Providing the consumer with activity formsand schedules for the consumer to complete for each worker.

Section G. Signatures

My ability to manage the CDC program has been assessed. If I do not agree with the results of this assessment, I must let the ASAP know and I have been informed of the process for resolving the disagreement.

I understand it is important that all participants in the CDC option understand their roles and responsibilities. I understand the CDC option is consumer-directed and I am the employer of my workers. I and my surrogate, if any, will be provided with a copy of this Agreement.

Signature of Consumer or Legal Guardian Date

Printed Name

I have assessed this consumer’s ability to manage the CDCoption.

Signature of Care Manager Date

Printed Name

This section must be completed for any consumer who requires a surrogate:

I agree to act as surrogate to assist the above-named consumer in managing his/her CDC services. I agree that the consumer will be involved in the management of the CDC option as much as he/she is capable. I understand, have the ability, and am responsible for the tasks as outlined in Section A B of this document. It is my responsibility to act in the best interest of the consumer.

Surrogate Information:

NamePhone Number

Street AddressCityZip

Surrogate relationship to the consumer Frequency of visits

Signature of SurrogateDate

Massachusetts Home Care Program/Consumer Directed Care

Rev. 7-2009Page 1 of 7